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- -- ---- ,- --- - <br />r ..� � <br />r <br />APPLICATION FOR PUBLIC WORKS PERMIT <br />� � Type or print cleerty wit� Ink / <br />� PRESS HARD - VOU ARE MAKING COPIES <br />PUBLIC WORKS PERMIT NO. �'�U� __ <br />EVERETT, WASHINGTON BLDG. DEPT. NO._ <br />47-OWNER ❑AGENT DATE _ `� Z_- <br />�' a 8. <br />APPLICANT/FIRM REPRESENTED _I4-�LzV4__�__.T�Tz-Ps/� J«-�_ _ <br />ADDRESS ?Z�.__�L�p,f]�— IS.L�— __CITY C��_TELE�'HONE `53- o'.5�� <br />HEREBY APPLIES FOR PEqMISSION TO _-4d_`I]�- �'LL- �kLS�S_�_r1;.� L Iw <br />L <br />ATTHE FOLLOWING LOCATION --______ `.���_�AI�.��'-_-�Q—. <br />Attech five (5) copies of preHminery plans for proposed work. Draw to scale and show the following as applicebie: <br />' Property Iines and street idendty. <br />' Out�ine and dimensions of existing and <br />proposed structures. <br />• Existing end proposed utflities. <br />• Centerline of abutting right of way. <br />' Topographic changes requiring cuts r•nd tills <br />other than normal foundation. <br />• On-site drainage systems when required. <br />• Eroslon control methods when required. <br />• North arrow <br />� •. <br />___�- ---------�-- <br />sipnelure ol Apo�icenl <br />PUBLIC WORKS PERMIT <br />CONDITIONS: <br />� ���i� � 1�� r";"�-._ . � <br />..�..... <br />��... <br />�.�.. j.......;_ <br />�'. ._,_._. _ ,. . . ... , . . . . . <br />......,:.:j ,.... <br />l...... .i ,.... <br />: .: ;_; :-i-, :_._i�_� ..�--:_:_:: <br />I . I _ <br />� <br />.;. <br />. __}_. . <br />f <br />.�. <br />:. :_; <br />. � 1 . . . . <br />__ -�/.,o'_ �r/ - J 8 �Z <br />)4��-- DATE----� <br />;: <br />/ <br />i/ <br />PERMIT IS V/,1LIb FOR 1 YEAR <br />i:XPIR�TION 3 � 8 � �� <br />�, <br />�.�';.L' <br />The untlersigned owner hereby eqreas lo hold antl eeve harmleee <br />Ihe City ol Everelt �rom eny ene eu clelme Iw Aemepe0. coete, <br />expanaee, or caueee ol ectlon Ihel mey e�lee 6eceuee ol lnelell�llon <br />enE melntenenre ol Ihe Improvement or olher rlphPol-wey uea <br />herelo opplied lor entl lurther e9reae to �amove eame upon nollce <br />Irom Iha Clty antl to replece puhlic propetly d�maQed Iheroby. <br />ACKNOWLEOGEMENT OF CONDITIONS <br />L , i � <br />SIGNATUREOF�APPLICAfJT � DATE <br />POST ON <br />JOBSITE <br />CALL FOR INSPECTION <br />259-8811 <br />24 HRS. BEFORE CON5TRUCTION <br />n�, <br />� <br />�� <br />�� � <br />